Pre-operative expectation predicts 12-month post-operative outcome among patients undergoing primary total hip replacement in European orthopaedic centres

The Needs and Experiences of Patients Returning to Work After Total Knee Arthroplasty and Total Hip Arthroplasty: A Systematic Review and Meta-Synthesis

OBJECTIVE

The objective of this study was to conduct a systematic and comprehensive review of qualitative research to examine the physical and psychological needs, as well as work experiences, of patients undergoing total knee replacement and total hip replacement surgeries during their process of returning to work.

METHODS

A systematic review and meta-synthesis of qualitative literature was conducted. A systematic search was conducted across 8 databases to identify qualitative or mixed-methods research on the needs and experiences of individuals with total knee replacement and total hip replacement who have returned to work. The search period extended from the inception of each database to March 2023. Two researchers independently utilized a predetermined search strategy to retrieve relevant English-language studies published in any year. The included studies were assessed for quality using the Critical Appraisal Skills Program appraisal tool. Findings from the studies were then summarized and integrated using the pooled integration method.

RESULTS

There were 10 studies in total. Three key themes were identified from the original research: needs during the return to work process and rehabilitation training, faith and support to return to work, and constraints and challenges at work.

CONCLUSION

Health care professionals and employers should conscientiously consider the physical and psychological requirements of patients who have undergone total knee replacement and total hip replacement when they are resuming work, taking into account the specific constraints and challenges that may arise in the workplace. To ensure a seamless transition back to work, it is essential to develop tailored occupational interventions, implement comprehensive return to work programs, and offer patients sufficient understanding and support.

IMPACT

The findings of this study offer valuable insights into the physical and psychological needs, as well as the work experiences, of patients who have undergone total knee replacement and total hip replacement during their reintegration into the workforce. These findings have the potential to assist health care professionals and employers in providing enhanced support to facilitate successful return-to-work outcomes for patients.

Evaluation of Patient Expectations and Outcomes after Distal Radius Fractures

BACKGROUND

Patient expectations influence patient-reported outcomes after musculoskeletal injuries. The goal of this study is to determine how pretreatment expectations correlate with outcomes in patients with distal radius fractures.

METHODS

Seventy-five patients with an isolated distal radius fracture were prospectively enrolled into nonoperative and operative cohorts. The Trauma Expectation Factor-Trauma Outcome Measure (TEF-TOM) score was the primary outcome measure. Trauma Expectation Factor scores were recorded at the time of enrollment, and TOM scores were recorded at 3, 6, and 12 months. Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) and Patient-Rated Wrist Evaluation (PRWE) scores were also recorded.

RESULTS

Trauma Outcome Measure scores at all time points were worse than expected (P < .01). Expectations were higher for patients younger than 65 years than for the 65+ group (P = .02). In patients aged 65+ years, mean TOM at 3 months was not significantly different than expected (P = .11) but decreased by 6 (P = .04) and 12 months (P < .01). Baseline TEF and TEF-TOM scores were not significantly different between operative and nonoperative groups (P = .37). Quick Disabilities of the Arm, Shoulder, and Hand and PRWE scores were not significantly different between age or treatment groups at the final follow-up.

CONCLUSIONS

The overall treatment of distal radial injuries in our study did not meet patient expectations. Patients aged 65 years or older had lower expectations but were not able to predict their outcomes better than patients aged <65 years. There were no differences in TEF or TOM by treatment method. Patients demonstrated improved functional outcomes (qDASH/PRWE) at all time points regardless of age and treatment method.

Analysis of patient-directed search content and online resource quality for ulnar collateral ligament injury and surgery

Background

Patients use the Internet to learn information about injuries, yet online content remains largely unstudied. This study analyzed patient questions posed online regarding ulnar collateral ligament (UCL) tears or UCL surgical management.

Methods

Three separate search strings about UCL tear and UCL surgery were queried on the Google search engine. The 300 most commonly asked questions were compiled for each topic and associated webpage information was collected from the "People also ask" section. Questions were categorized using the Rothwell classification and webpages by Journal of the American Medical Association (JAMA) benchmark criteria.

Results

The most frequent UCL tear questions were "how long does it take to heal a torn UCL?" and "what is nonsurgical treatment for the UCL?" The most frequent UCL surgery question was "can you retear your UCL after surgery?" The Rothwell classification of questions for UCL tear/UCL surgery was 55%/32% policy, 38%/57% fact, and 7%/11% value with highest subcategories being indications/management (46%/25%) and technical details (24%/25%). The most common webpages were academic (39%/29%) and medical practice (24%/26%). Mean JAMA score for all 600 webpages was low (1.2), with journals (mean = 3.4) having the highest score. Medical practice (mean = 0.5) and legal websites (mean = 0.0) had the lowest JAMA scores. Only 30% of webpages provided UCL-specific information.

Conclusion

Online UCL patient questions commonly pertain to technical details and injury management. Webpages suggested by search engines contain information specific to UCL tears and surgery only one-third of the time. The quality of most webpages provided to patients is poor, with minimal source transparency.

Preoperative expectations, postoperative satisfaction and patient directed priorities for clinical burn research

INTRODUCTION

Burn patients receiving split thickness skin grafting are left with scarring and chronically dysfunctional grafted skin. Given evidence that patients' preoperative expectations mediate postoperative outcomes and satisfaction, we described burn patients' experience, expectations, and satisfaction with their skin graft, their views towards a cell based clinical trial to improve their graft and identified graft outcome measures for use in future studies.

METHODS

Data were collected via questionnaires preoperatively, one, and three months postoperatively. Longitudinal analyses assessed change over time.

RESULTS

Expectations of graft function were consistent pre- and postoperatively. Expectations of graft appearance showed significant decrease over time (β1 = -0.290, p = 0.008). Significant improvements in skin function (β1 = 0.579, p = 0.000) and appearance (β1 = 0.247, p = 0.025) at the wound site during recovery were observed. Patients noted great difference between grafted and normal skin. Patient satisfaction with their graft did not change significantly over time. Patients were willing to participate in a cell based clinical trial to improve graft symptomology and prioritized improvements in scarring, redness, sensation, and elasticity.

CONCLUSIONS

Outcome measures in trials advancing skin grafting should reflect chronic, patient prioritized limitations. We recommend preoperative educational interventions for burn patients receiving grafting to improve postoperative satisfaction.

Rehabilitation Phases, Precautions, and Mobility Goals Following Total Hip Arthroplasty

The prevalence of total hip arthroplasty (THA) for advanced hip osteoarthritis (OA) is both increasing and shifting toward a younger average age. However, THA alone does not typically normalize function in these patients. Postoperative rehabilitation is often recommended to optimize joint motion, strength, and function. To date, there are no peer-reviewed clinical practice guidelines for postoperative rehabilitation following THA. Thus, optimal postoperative rehabilitation requires consideration of the existing literature and clinical expertise. This review article summarizes current recommendations for postoperative management of THA, including phases of rehabilitation, postoperative hip precautions, the effect of rehabilitation setting and mode of delivery on postoperative outcomes, and gait mechanics.

Patient Expectations and Satisfaction in Pediatric Orthopedics

PURPOSE OF REVIEW

The purpose of the current review is to analyze the current literature regarding the tools available to evaluate patient expectations and satisfaction. There have been an increasing number of tools that have been developed and validated for various orthopedic procedures. Despite the growing number of tools, there are a limited number of tools available for pediatric patients.

RECENT FINDINGS

Several tools have been developed in orthopedics to evaluate patient expectations. However, there are no tools that have been validated in the pediatric population. In addition, pediatric patient expectations should be collected in conjunction with parent/caregiver expectations. Although not specifically validated for pediatric patients, there are several tools available that may pertain to pediatric patients including the HSS ACL Expectations Survey, HSS Shoulder Expectations Survey, HSS Knee Surgery Expectations Survey, HSS Foot and Ankle Surgery Expectation Survey, Sunnybrook Surgery Expectations Survey, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments, Quick DASH, and DASH. In terms of patient satisfaction, there are even fewer tools available. Several tools have been developed to evaluate patient satisfaction and five additional tools within orthopedics. Of these tools, there are two that have been validated for pediatric patients: The Swedish Parents Satisfaction Questionnaire and the Scoliosis Research Society-22. There are a growing number of tools to evaluate patient's expectations and satisfaction in the orthopedic literature. Given most of these tools pertain to adult patients, there is a need for further development of tools specifically validated for pediatric patients and their parents/caregivers. Through the measurement of expectations and satisfaction, medical professionals can hope to improve satisfaction and outcomes.

Development and psychometric validation of the hospitalized patients' expectations for treatment scalepatient version

Objectives

A general expectation measurement of inpatients across wards is needed in the patient safety management systems of general hospitals. This study developed and psychometrically validated a new scale fulfilling the requirements above: the Hospitalized Patients' Expectations for Treatment Scale-Patient version (HOPE-P).

Methods

A total of 35 experts and ten inpatients were interviewed during the formulation of the HOPE-P scale, which was initially designed with three dimensions: doctor-patient communication expectations, treatment outcome expectations, and disease management expectancy. We recruited 210 inpatients from a general hospital in China and explored the reliability, validity, and psychometric characteristics of the questionnaire. Item analysis, construct validity, internal consistency and 7-day test-retest reliability analysis were applied.

Results

Exploratory and confirmatory analyses supported a 2-dimension (doctor-patient communication expectation and treatment outcome expectation) structure with satisfactory model fit parameters (root mean square residual (RMR) = 0.035, a root-mean-square-error of approximation (RMSEA) = 0.072, comparative fit index (CFI) = 0.984, Tucker-Lewis index (TLI) = 0.970). Item analysis revealed an appropriate item design (r = 0.573-0.820). The scale exhibited good internal consistency, with Cronbach's α of 0.893, 0.761, and 0.919 for the overall scale, the doctor-patient communication expectation subscale, and the treatment outcome expectation subscale, respectively. The 7-day test-retest reliability was 0.782 (p < .001).

Conclusion

Our results indicated that the HOPE-P is a reliable and valid assessment tool to measure the expectations of general hospital inpatients, with a strong capacity to recognize patients' expectations regarding doctor-patient communication and treatment outcomes.

Parental Caregiver Expectations and Satisfaction Following Hip Reconstruction and Spinal Fusion in Children With Cerebral Palsy

Children with severe (Gross Motor Function Classification System [GMFCS] IV-V) cerebral palsy (CP) exhibit profound physical and developmental impairments and require assistance for all activities of daily living. No curative treatments exist although surgical procedures to correct underlying hip and spine deformities can improve their quality of life. Despite the efficacy of these surgeries, little is known regarding parental caregivers' expectations specific to surgical outcomes and their satisfaction with surgical outcomes. The purpose was to explore parental caregiver expectations and satisfaction with hip and spine surgeries that their children with GMFCS IV-V CP underwent. Variations among preoperative expectations, changes in expectations over time, and the relationship of expectations on caregiver satisfaction were examined. A qualitative descriptive approach with conventional content analysis was utilized. Three preoperative caregiver expectation themes were identified: increasing functionality, increasing comfort, and maintaining health and averting crisis. These themes were still present at 5-year follow-up; however, more caregivers refocused their expectations from improving function to providing palliation. A clear relationship between expectations and caregiver satisfaction, however, was not identified. A deeper understanding surrounding caregiver expectation and satisfaction following surgical procedures is needed.

Are contextual factors associated with activities and participation after total hip arthroplasty? A systematic review

OBJECTIVES

After total hip arthroplasty (THA), over 30% of individuals report activity limitations and participation restrictions. This systematic review aimed to determine the association between contextual factors and outcomes in the activity and participation domain after THA for hip osteoarthritis (OA).

METHODS

This systematic review was developed according to the PRISMA guidelines for systematic reviews. PubMed, Web of Science, Embase and Scopus were searched until August 2022. Risk of bias was assessed with the Quality in Prognosis Studies tool (QUIPS).

RESULTS

Twenty-nine articles were included. Eighteen had a high risk of bias, 3 had a low risk of bias, and 8 had a moderate risk of bias. Anxiety was only investigated in studies with high risk of bias but showed a consistent negative association with activities and participation after THA across multiple studies. Evidence was inconsistent regarding the associations between depression, trait anxiety, sense of coherence, big 5 personality traits, educational level, marital status, employment status, job position, expectations and social support, and the activity and participation domain. Optimism, general self-efficacy, cognitive appraisal processes, illness perception, ethnicity, and positive life events were associated with activities and participation but were only investigated in 1 study. No associations were identified across multiple studies for living or smoking status. Control beliefs, kinesiophobia, race, discharge location, level of poverty in neighbourhood, negative life events and occupational factors, were not associated with the activity and participation domain but were only investigated in 1 study.

CONCLUSION

Methodological quality of the included studies was low. Anxiety was the only factor consistently associated with worse outcomes in the activity and participation domain after THA but was only investigated in studies with high risk of bias. Further research is needed to confirm relationships between other contextual factors and activities and participation after THA.

REGISTRATION

PROSPERO CRD42020199070.

Higher preoperative expectations predict better outcomes in shoulder surgery patients

PURPOSE

The purpose of this study is to determine if preoperative expectations (PE) are an independent predictor of greater 2-year outcomes and greater improvement from baseline in shoulder surgery patients.

METHODS

Two-hundred and sixteen patients who underwent shoulder surgery at one institution were studied. Patients completed both preoperative and 2-year follow-up questionnaires including PROMIS (Patient-Reported Outcome Measurement Information System) computer-adaptive testing in six domains, American Shoulder and Elbow Surgeons (ASES) score, shoulder numeric pain scale (NPS), and the Marx Shoulder Activity Rating Scale (MARS). PE were measured using the Musculoskeletal Outcomes and Data Evaluation Management System (MODEMS) expectations domain, and satisfaction was measured via the Surgical Satisfaction Questionnaire (SSQ-8).

RESULTS

The mean PE score was 86.2 ± 17.8. Greater PE were associated with significantly better 2-year scores for ASES, NPS, MARS, SSQ8, and PROMIS domains of Physical Function, Fatigue, Pain Interference Fatigue and Social Satisfaction. Multivariable analyses demonstrated that greater PE were an independent predictor of both better 2-year scores and greater improvement for PROMIS SS (p < 0.001), ASES (p = 0.007), and shoulder NPS (p = 0.011).

CONCLUSION

Greater PE are positively associated with numerous patient-based outcomes 2 years after surgery. With regards to pain relief, shoulder function, and social satisfaction, higher PE are also predictive of better outcome scores and more improvement. This study suggests that preoperative assessment of shoulder surgery PE is important, and that counseling patients to optimize realistic expectations may lead to superior outcomes.

LEVEL OF EVIDENCE

III.

Participation of patients during arthroscopic partial meniscectomy is conducive to postoperative rehabilitation and satisfaction: a single-center retrospective study

PURPOSE

To evaluate the effect of patient participation in arthroscopic partial meniscectomy (APM) on rehabilitation and patient satisfaction.

METHODS

A total of 86 patients of traumatic longitudinal vertical meniscus tears, between January 2017 and December 2020 at the First Affiliated Hospital of Zhejiang Chinese Medical University, met the inclusion and exclusion criteria. The patients in the intraoperative participation group (n = 33) were awake and could watch the screen during APM and communicate with the surgeon in the surgery; patients who underwent APM in the traditional mode were classified as the traditional group(n = 53). The differences in exercise adherence, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and satisfaction at follow-up were compared. In the intraoperative participation group, the mean age of the patients was 26.97 ± 5.63 years and the follow-up time was 25.12 ± 6.23 months. In the traditional group, the mean age of the patients was 29.21 ± 5.29 years and the follow-up time was 25.08 ± 6.70 months.

RESULTS

The intraoperative participation group reported a better result in exercise adherence (78.79% VS 50.94%, p = 0.012). As secondary outcomes, Patients in the intraoperative participation group demonstrated better scores on the KOOS domains of pain (79.80 ± 6.38 VS 76.26 ± 5.33, p = 0.007), Symptoms (59.41 ± 5.27 VS 56.74 ± 5.97, p = 0.038), and QOL (65.91 ± 10.72 VS 60.26 ± 9.34, p = 0.012), as compared to these in the traditional group. There were no significant differences in the KOOS domains of Sport (72.88 ± 8.20 VS 72.64 ± 7.70, P = 0.892), and ADL (89.47 ± 3.50 VS 87.87 ± 4.50 p = 0.085). what's more, in the intraoperative participation group, the results of satisfaction (96.97% VS 81.13%, p = 0.025) were also significantly better.

CONCLUSION

The mode of participation of patients during APM can improve patients' exercise adherence, reduce pain, improve symptoms and improve patients' satisfaction as well as the quality of life. More work is needed to develop this mode further.

Preoperative Factors and Patient-Reported Outcomes After Total Hip Arthroplasty: Multivariable Prediction Modeling

BACKGROUND

Although total hip arthroplasty (THA) has been established as a cost-effective intervention, some patients experience ongoing pain and dissatisfaction. There is interest in predicting postoperative outcomes based on preoperative data, but the relative contribution of different preoperative factors is unclear. The study's aim was to develop multivariable prediction models for the assessment of patient-reported outcomes.

METHOD

Registry data on 1412 patients undergoing THA for osteoarthritis at two hospitals between 2013 and 2018 was used. Potential predictors included age, sex, body mass index, spoken language, education level, previous THA, American Society of Anaesthesiologists (ASA) score, lower back pain, depression/anxiety, other lower limb arthritis, number of other comorbidities, the preoperative expectation of pain and function, EuroQol Visual Analogue Scale (EQ-VAS) and preoperative OHS. Radiographic scores were also used: joint space narrowing (JSN), osteophytes, sclerosis, and an overall grade based on the Kellgren-Lawrence (KL) classification. Outcomes assessed were the patient-rated improvement, satisfaction, and OHS at six months.

RESULTS

JSN or overall KL scores were the most important predictors (P < .001) for all outcomes, with better radiographic scores associated with worse outcomes. Other predictors associated with poorer outcomes were lower back pain and lower expectation (predicting poor improvement), lower education and higher ASA (predicting lower satisfaction) and younger age, female sex, non-English speakers, lower preoperative EQ-VAS, lower education, back pain, and anxiety/depression (predicting lower OHS).

CONCLUSION

Preoperative radiological scores are an important predictor of patient-reported outcomes at six months postoperatively. Understanding the relative strengths and significance of different factors in predicting outcomes will help the clinician and patient decision-making for THA.

Characterizing preoperative expectations for patients undergoing reverse total shoulder arthroplasty

BACKGROUND

There remains a paucity of information analyzing which factors most influence preoperative expectations for patients undergoing reverse total shoulder arthroplasty (RTSA). The purposes of our study were to characterize preoperative patient expectations for those scheduled to undergo RTSA and to determine the impact of demographic factors, shoulder function, and shoulder pain on these preoperative expectations.

METHODS

Patients were prospectively recruited into the study if they were scheduled to undergo an elective unilateral primary RTSA for a diagnosis of glenohumeral arthritis. Preoperative patient expectations were evaluated using the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Patients also completed the American Shoulder and Elbow Surgeons shoulder score, the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function-Upper Extremity computer adaptive test (version 2.0), the PROMIS Pain Interference (PI) computer adaptive test (version 1.1), the PROMIS Depression computer adaptive test (version 1.0), visual analog scores, and an itemized satisfaction questionnaire, which paralleled the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Demographic data and preoperative shoulder range of motion (ROM) were also recorded.

RESULTS

A total of 107 patients scheduled to undergo RTSA were included in the study. Relief of daytime pain (n = 91, 85%), improvement in self-care (n = 86, 80%), and improvement in shoulder ROM (n = 85, 79%) were most commonly cited as "very important" expectations. In the item-specific analysis, lower PROMIS Upper Extremity scores were correlated with greater expectations for the ability to reach sideways (P = .015) and the ability to perform daily activities (P = .018). Patients with lower shoulder ROM had greater expectations for improved shoulder ROM (internal rotation with arm at 90°, P = .004) and an improved ability to perform daily activities (forward elevation, P = .038; abduction, P = .009). In the cumulative analysis, a greater number of very important expectations was associated with African American race (P = .013), higher PROMIS PI score (r = 0.351, P = .004), and lower overall preoperative satisfaction (r = 0.334, P < .001).

CONCLUSION

Patients scheduled to undergo RTSA have the greatest expectations for relief of daytime pain, improvement in self-care, and improvement in shoulder ROM. Patients with limited preoperative ROM have greater expectations for improvement in self-care and the ability to perform daily activities in addition to expectations for improvement in shoulder ROM. Greater overall expectations for surgery were not associated with preoperative physical function but were instead associated with lower preoperative satisfaction and higher PROMIS PI scores.

Overstretching Expectations May Endanger the Success of the “Millennium Surgery”

Total hip arthroplasty (THA) is an extremely successful treatment strategy. Patient expectations, however, have increased; if not properly guided by surgeons, at present, patients expect next to pain-free restoration of the joint and a fast return to work and sports. While the revision rates after THA also increased in younger patients, knowledge on musculoskeletal loads still remains sparse, and the current recommendations on postoperative rehabilitation are based on expert opinions only. The aim of this study was to unravel biomechanical contact conditions in “working age” (&lt;60 years, 53.5 ± 3.0 years) and “retirement age” (&gt;60 years, 67.7 ± 8.6 years) patients during activities recommended post-THA. We hypothesized that working age patients would show substantially increased hip contact loads compared to older patients. The in vivo joint contact force (Fres) and torsion torque (Mtors), reflecting the main contact load situation, experienced during activities of daily living and sports activities were measured in a unique group of 16 patients with instrumented THA. We summarized patient activities and sports recommendations after THA mentioned within the literature using PubMed (without claim of completeness). The measurements showed that younger working age patients experienced significant (p = 0.050) increased Mtors (21.52 ± 9.11 Nm) than older retirement age patients (13.99 ± 7.89 Nm) by walking. Bowling, as a recommended low-impact sport, was associated with Fres of up to 5436 N and Mtors of up to 108 Nm in the working age group, which were higher than the Fres (5276 N) and Mtors (71 Nm) during high-impact soccer. Based on our results, age was proven to be a discriminator in joint loading, with working age patients presenting with increased loads compared to retirement age patients, already during daily activities. The current patient recommendations have led to further increased joint loadings. If THA cannot be delayed in a patient, we propose counselling patients on a carefully considered return to sports, focusing on low-impact activities, as indicated hereby. The findings from this work illustrate the need to provide critical feedback to patient expectations when returning to work and sports activities. Patients returning to more intensive sports activities should be carefully monitored and advised to avoid as much overloading as possible.

Moderate relationship between function and satisfaction of total hip arthroplasty patients: a cross sectional study

PURPOSE

Patient satisfaction regarding their hip replacement is often assumed to be directly linked to functional outcomes. We led this study to answer 2 questions: (1) what is the level of patient satisfaction, function, and quality of life after primary total hip replacement (THR); and (2) what is the relationship between patient satisfaction and functional and quality of life PROMs after THR?

METHODS

We led a retrospective study using our institutional registry of prospectively and consecutively collected data on patients after primary THR undertaken between 2004 and 2017. We included 6710 patients with a complete 2-year set of follow-up data for Oxford Hip Score (OHS) (for assessing patient's function), EQ-5D (for assessing patient's quality of life) and satisfaction PROM scores.

RESULTS

There was a significant improvement in all OHS and EQ-5D scores from preoperative level, and the mean postoperative satisfaction score was 89/100. We found moderate positive correlations between the patients' outcome satisfaction VAS score and OHS (r = 0.665) and EQ-5D (r = 0.554).

CONCLUSIONS

THR is a successful procedure generating high levels of patient function and satisfaction. Because patients' OHS and EQ-5D scores may be influenced by comorbidities, those scores are of poor predictive value in estimating patient satisfaction, and therefore should not be used as a surrogate to determine the success of the THR procedure.

Meeting Patient Expectations or Achieving a Minimum Clinically Important Difference: Predictors of Satisfaction Among Lumbar Fusion Patients

Study Design

Retrospective cohort.

Purpose

To investigate the impact of meeting a patient’s preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion.

Overview of Literature

Few studies have compared if MCID achievement or meeting preoperative expectations for pain reduction affects patient satisfaction.

Methods

A surgical database was reviewed for eligible patients who underwent lumbar fusion. Patient satisfaction and Visual Analog Scale (VAS) for back and leg pain were the outcomes of interest. Meeting expectations was calculated as a difference of ≤0 between preoperative expectations and postoperative VAS scores. MCID achievement was calculated by comparing changes in VAS scores with established values. Meeting preoperative expectations or MCID achievement as predictors of patient satisfaction was evaluated using regression analysis.

Results

A total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back and VAS leg (p<0.001). At 1 year, 56.4% of patients had their VAS back expectations met compared with 59.5% for VAS leg. Similarly, at 1 year, 77.3% and 71.3% of patients achieved MCID for VAS back and leg, respectively. Meeting expectations for VAS back was significantly associated with patient satisfaction at all postoperative timepoints; however, MCID achievement only demonstrated a significant association with patient satisfaction at 6 and 12 weeks (all, p≤0.024). Meeting VAS leg expectations and MCID achievement both demonstrated a significant association with patient satisfaction at all postoperative timepoints (all, p≤0.02). No differences between MCID achievement and meeting expectations as predictors of satisfaction were noted.

Conclusions

The majority of patients achieved MCID and had their back and leg pain expectations met by 1 year. Both measures were significant predictors of patient satisfaction and suggest that MCID achievement may act as a suitable substitute for patient satisfaction.

The Relationship Between Patient Expectations and Functional Outcomes in Patients Undergoing Cartilage Repair of the Knee: A Mixed Methods Study

CONTEXT

Patient expectations have been shown to be a major predictor of outcomes. Fulfilled expectations have been linked to increased patient satisfaction and rehabilitation adherence. Expectations may be influenced by a variety of factors, including patient characteristics, preoperative function, or disease characteristics. It is currently unknown what factors may influence patient expectations prior to cartilage repair of the knee, and to what degree. Furthermore, understanding the importance and values of those expectations for recovery using mixed methods has not previously been conducted in this patient population. The purpose of this mixed methods study is to examine and explore the relationships between patient expectations and functional outcome in patients undergoing cartilage repair of the knee.

DESIGN

A mixed methods design was used.

METHODS

Twenty-one patients scheduled to undergo cartilage repair of the knee were included. Participants completed the Hospital for Special Surgery Knee Surgery Expectations Survey and the Knee Injury and Osteoarthritis Outcome Score at their preoperative visit. Knee Injury and Osteoarthritis Outcome Scores were also obtained at 3 and 6 months postsurgery. A selected sample of 6 participants participated in semi-structured interviews 6 months postsurgery. Pearson correlation coefficients were used to determine relationships between expectations and functional outcome.

RESULTS

Patients have moderate expectations for recovery, and these expectations were positively associated with preoperative pain, activities of daily living, and quality of life. Expectations also correlated with symptoms 3 months postsurgery, but there were no other significant correlations between preoperative expectations and postoperative function in the short term. Four qualitative themes emerged as participants described how previous recovery experiences shaped their expectations.

CONCLUSIONS

Formalized patient and caregiver education, prehabilitation, and the use of psychological skills during rehabilitation may help to manage patient expectations and provide more focused and individualized care, thus improving outcomes.

Effect of marital status on patient-reported outcomes following total hip arthroplasty: a matched analysis with minimum 2-year follow-up

INTRODUCTION

Mental health and patient expectation have been identified as key predictors of recovery following THA; however, there is limited literature examining the effects of social support and marital status on patient-reported outcomes (PROs).

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent THA between July 2008 and January 2016. Patients were included if they underwent primary THA during this period and if they had documented preoperative marital status of married, divorced, or never married. Married patients were group matched to non-married patients (divorced or never married) with similar sex, age, body mass index (BMI), gender distribution, and frequency of surgical approach.

RESULTS

There were 414 married patients and 98 non-married patients who were eligible and had minimum 2-year follow-up. Mean PROs were significantly worse in the non-married group than the married group for the following measures: modified Harris Hip Score (p = 0.002), Harris Hip Score (p = 0.002), Forgotten Joint Score (p = 0.04), and the physical portions of the Veterans RAND (p = 0.025) and Short Form (p = 0.02) surveys.

CONCLUSIONS

Our study demonstrated inferior absolute PRO scores at latest follow-up for patients who were non-married compared to married following THA. These results show that while total hip replacement may still yield clinical benefit in all patients, non-married patients may ultimately achieve an inferior functional status, and expectations should be adjusted accordingly. Physicians should assess levels of psychosocial support in their patients prior to undergoing hip arthroplasty in order to optimise results.

Patient Mindset and the Success of Carpal Tunnel Release

BACKGROUND

Depression and pain catastrophizing are aspects of the patient's mindset that have been shown to be important in relation to the outcome of carpal tunnel release. However, other factors of the patient's mindset have been understudied, such as treatment expectations and illness perceptions. The aim of the present study was to investigate the influence of these mindset aspects on outcome of carpal tunnel release, in addition to psychological distress and pain catastrophizing.

METHODS

A total of 307 patients with carpal tunnel syndrome who visited outpatient hand surgery clinics and who completed online questionnaires regarding demographic and psychosocial characteristics and carpal tunnel syndrome severity were included. The patient mindset was measured with the Patient Health Questionnaire-4, the Pain Catastrophizing Scale, the Credibility Expectancy Questionnaire, and the Brief Illness Perception Questionnaire. Hierarchical linear regression models were used to examine the relation between self-reported severity 6 months after carpal tunnel release, as measured with the Boston Carpal Tunnel Questionnaire, and psychosocial aspects of mindset, adjusting for preoperative Boston Carpal Tunnel Questionnaire score, patient characteristics, and comorbidities.

RESULTS

Independent associations with better self-reported outcome were found for higher treatment expectations (β = -0.202; p < 0.001) and illness comprehensibility (β = -0.223; p < 0.001). The additional explained variance in Boston Carpal Tunnel Questionnaire scores by the patient's mindset was 13.2 percent (psychological distress and pain catastrophizing together, 2.1 percent; treatment expectations and illness perceptions together, 11.1 percent).

CONCLUSION

Treatment outcome expectations and comprehensibility of illness are both independently associated with the outcome of carpal tunnel release, showing the importance of these aspects of the patient's mindset for the outcome of carpal tunnel release.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Patient expectations predict outcomes following distal radius fracture: a prospective cohort study using the TEFTOM questionnaire

INTRODUCTION

The relationship between patient expectations and clinical outcomes has recently been of increasing interest in the field of orthopaedics. The objective of this study was to evaluate the relationships between (1) patient pre-treatment expectations and post-treatment clinical outcomes, and (2) fulfillment of expectations and patient satisfaction, following distal radius fracture.

METHODS

This was a prospective multicenter cohort study conducted across three hospitals. A total of 133 patients admitted to hospital between 2016 and 2018 with a distal radius fracture were recruited. Patients were administered the Trauma Expectation Factor (TEF) at baseline to measure expectations of pain and functioning at one-year post-injury. Patients were followed up at 6 and 12 months post-injury and outcomes were measured using the Trauma Outcome Measure (TOM), Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, and Short-Form 12-item (SF-12) health survey. Fulfillment of expectations was measured as TEF score minus TOM score at each time point. Patient satisfaction was also measured using the Patient Satisfaction Questionnaire Short Form (PSQ-18). Multivariate regression models were created to evaluate the effect of expectations on outcomes.

RESULTS

Patient expectations correlated moderately with outcomes at 6 and 12 months post-injury. In the multivariate analysis, patient expectations were predictive of better outcomes at 6 and 12 months. Injury severity, age, mechanism of injury, and whether the injury occurred on duty also contributed significantly to one or more regression models. Patient satisfaction correlated weakly with fulfillment of expectations at 6 months, but moderately with all outcome scores. At 12 months, satisfaction did not correlate significantly with expectations fulfillment but correlated moderately to highly with all outcome scores.

CONCLUSION

Patient expectations independently predicted outcomes at 6 and 12 months post-injury. Standardized assessment and management of patient expectations may be relevant to future clinical practice and research to best quantify and optimize patient outcomes.

Predictors of met expectations two years after knee surgery

Introduction

The purpose of this study is to determine which patient factors predict two-year postoperative met expectations in a cohort of patients undergoing knee surgery. Additionally, this study aims to measure the association between met expectations and postoperative outcomes.

Methods

319 patients undergoing knee surgery at one institution were studied. Patients completed patient-reported outcome questionnaires prior to surgery and again two years postoperatively. Preoperative Expectations and postoperative Met Expectations were measured using the Musculoskeletal Outcomes and Data Evaluation Management System (MODEMS) Expectations domain.

Results

The mean Met Expectations score was significantly lower than the preoperative Expectations Score. Worse two-year Met Expectations were associated with older age, higher BMI, greater comorbidities, more previous surgeries, black race, unemployment, lower income, government insurance, Worker's Compensation, smoking, and no injury prior to surgery. Greater Met Expectations were correlated with better scores on all two-year outcome measures as well as greater improvement on most outcome measures. Race, insurance status, function, mental health, and knee pain were found to be independent predictors of Met Expectations.

Conclusion

This study identified multiple patient factors and outcome measures that were associated with Met Expectations two years after knee surgery.

Patients With Higher Treatment Outcome Expectations Are More Satisfied With the Results of Nonoperative Treatment for Thumb Base Osteoarthritis: A Cohort Study

OBJECTIVE

To investigate how satisfaction with treatment outcome is associated with patient mindset and Michigan Hand Outcome Questionnaire (MHQ) scores at baseline and 3 months in patients receiving nonoperative treatment for first carpometacarpal joint (CMC-1) osteoarthritis (OA).

DESIGN

Cohort study SETTING: A total of 20 outpatient locations of a clinic for hand surgery and hand therapy in the Netherlands.

PARTICIPANTS

Patients (N=308) receiving nonoperative treatment for CMC-1 OA, including exercise therapy, an orthosis, or both, between September 2017 and February 2019.

INTERVENTIONS

Nonoperative treatment (ie, exercise therapy, an orthosis, or both) MAIN OUTCOME MEASURES: Satisfaction with treatment outcomes was measured after 3 months of treatment. We measured total MHQ score at baseline and at 3 months. As baseline mindset factors, patients completed questionnaires on treatment outcome expectations, illness perceptions, pain catastrophizing, and psychological distress. We used multivariable logistic regression analysis and mediation analysis to identify factors associated with satisfaction with treatment outcomes.

RESULTS

More positive pretreatment outcome expectations were associated with a higher probability of being satisfied with treatment outcomes at 3 months (odds ratio, 1.15; 95% confidence interval, 1.07-1.25). Only a relatively small part (33%) of this association was because of a higher total MHQ score at 3 months. None of the other mindset and hand function variables at baseline were associated with satisfaction with treatment outcomes.

CONCLUSIONS

This study demonstrates that patients with higher pretreatment outcome expectations are more likely to be satisfied with treatment outcomes after 3 months of nonoperative treatment for CMC-1 OA. This association could only partially be explained by a better functional outcome at 3 months for patients who were satisfied. Health care providers treating patients nonoperatively for CMC-1 OA should be aware of the importance of expectations and may take this into account in pretreatment counseling.

Evaluation of an expectation and outcome measurement questionnaire in ankle fracture patients: The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) Eurasia study

BACKGROUND

The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) questionnaire is a self-administered, patient-rated outcome measurement questionnaire designed to measure both 'expectation' and 'outcome' in orthopaedic trauma patients using two subsets of 10 items. We aimed to validate this instrument in a culturally diverse cohort of patients recruited from Asian and European regions.

METHODS

A total of 193 adult patients with surgically treated AO Foundation/Orthopaedic Trauma Association types 43 and 44 ankle malleolar and distal tibia fractures were recruited with 158 followed up till 1 year. Expectations were assessed prior to surgery, at 2 weeks and after 6 months using the trauma expectation factor (TEF) score. Outcomes were evaluated at 2 weeks, 6 and 12 months using the trauma outcome measure (TOM), American Academy of Orthopaedic Surgeons (AAOS), foot and ankle outcome score (FAOS) and short form-36 (SF-36) questionnaires. Psychometric properties of TEFTOM were assessed.

RESULTS

TEF and TOM demonstrated good internal consistency (Cronbach's α > 0.87) and reliability at all time points (intra-class correlation coefficients > 0.90). TOM showed strong correlations (R² ≥ 0.60) with the AAOS foot and ankle score, all FAOS subscales, except 'symptoms' and SF-36 physical functioning, role physical, bodily pain, social functioning and the physical component summary at 6 and 12 months. Effect sizes for TOM were 2.30 and 0.74 from 2 weeks to 6 months and from 6 months to 12 months, respectively. The baseline patient TEF was predictive for the 1-year TOM score.

CONCLUSIONS

TEFTOM demonstrated good psychometric properties in this cohort of patients with ankle fractures. The TEF 'expectation' score was predictive of the TOM 'outcome' score. We recommend researchers and clinicians to utilize TEFTOM when patient expectation measurement is concerned for orthopaedic trauma patients.

Preoperative expectations and early postoperative met expectations of extremity orthopaedic surgery

BACKGROUND

Preoperative patient expectations and met expectations are likely associated with the outcome of treatment. However, there is a lack of data regarding the preoperative expectations and early postoperative met expectations of patients undergoing extremity orthopaedic surgery. The purpose of this study was to identify the predictors of early postoperative met expectations in a cohort of patients undergoing extremity orthopaedic surgery and to assess the relationship between patient expectations and patient-reported outcome (PRO) measures. We hypothesized that patients with higher preoperative expectation scores and higher postoperative met expectation scores would have better early postoperative outcomes.

METHODS

Four hundred thirty-five patients age seventeen and older who underwent extremity orthopaedic surgery at one institution were prospectively enrolled in this study. Each patient completed a preoperative questionnaire that included an assessment of demographics, pain, function, general health, treatment expectations, activity level, and Patient-Reported Outcome Measurement Information System (PROMIS) computer adaptive testing. Expectations were evaluated using the Expectations Domain of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire. Patients completed a follow-up questionnaire two weeks after surgery that also assessed MODEMS met expectations and satisfaction (Surgical Satisfaction Questionnaire (SSQ-8)).

RESULTS

The mean preoperative expectation score was 86.95 ± 16.59, and the mean postoperative met expectation score was 55.02 ± 27.63 (0-100 scale with 100 representing the highest level of expectations). Greater met expectations were significantly associated with white race (p = 0.025), college degree (p = 0.011), and higher income (p = 0.002). Greater met expectations were also significantly associated with greater postoperative physical function, social satisfaction, activity level, and subjective improvement, as well as lower pain interference, joint pain, body pain, fatigue, anxiety, and depression (p < 0.01 for each). Multivariable analysis results found that less postoperative joint pain and greater postoperative social satisfaction, improvement, and physical function were all significant independent predictors of greater met expectations at two weeks postoperative (p < 0.01 for each).

CONCLUSION

Greater preoperative expectations are associated with better activity and less pain two weeks after surgery. Met expectations of extremity orthopaedic surgery were associated with postoperative physical function, social satisfaction, activity, pain, anxiety, depression, and subjective improvement. These results may have implications for preoperative counseling and risk factor modification.

High Pre-Operative Expectations Precede Both Unfulfilled Expectations and Clinical Improvement After Total Hip and Total Knee Replacement

BACKGROUND

This prospective study aimed to examine whether patients' and physicians' outcome expectations were related to subjective (ie, fulfillment of expectations) and objective outcomes (ie, change in pain and function) in hip and knee arthroplasty patients up to 6 months post-surgery.

METHODS

Patients' (N = 395) and physicians' outcome expectations were examined 1 week post-consultation. Patients' post-operative functional status and the extent of fulfillment of expectations were examined 5 weeks, 3 months, and 6 months post-surgery. Patients and physicians completed the Hospital for Special Surgery Hip/Knee Replacement (Fulfillment) Expectations Survey. Patients completed the Hip/Knee injury and Osteoarthritis Outcome Score. Linear regression analyses were performed to examine the relationship between physicians' expectations and patients' change in pain and function and extent of fulfillment of expectations, and a possible mediated effect of patients' pre-operative expectations.

RESULTS

Patients' high expectations were consistently associated with better objective outcomes (ie, change in pain and function). Yet, high expectations in patients were also negatively related to subjective outcomes (ie, the extent of fulfillment of expectations). Physicians' expectations were only positively associated with objective improvement in knee patients, and not in hip patients. Additionally, knee patients' expectations partly mediated the relationship between physicians' expectations and change in pain and function, 6 months post-surgery.

CONCLUSION

Although patients' high expectations were associated with better objective outcomes, improvement was still less than patients expected. Thus, patients often have too high expectations of outcomes of surgery. In addition, physicians were able to influence patients' expectations and to change experienced knee patients' outcomes.

Characterizing patients' expectations in hip and knee osteoarthritis

PURPOSE

Previous research reported conflicting findings regarding the association of sociodemographic and clinical variables with expectations for surgical outcomes. The current study aimed to identify and characterize different subgroups of osteoarthritis patients with respect to amount and level of expectations, and to examine factors that are associated with expectations.

METHODS

Hip and knee patients (n = 287) completed a questionnaire 1 week post consultation. Linear regression analyses were performed to examine whether sociodemographic (e.g., age, sex) and clinical factors (e.g., pain, function) were associated with expectations. Latent class analysis (LCA) was used to identify different subgroups and the step 3 method was conducted to assess subgroup characteristics.

RESULTS

Mean age of patients was 70 years (SD = 8) and 57% of patients was female. Most improvement was expected in walking ability and pain relief. Higher expectations were associated with younger age, male sex, and functional disability. Both hip and knee patients could be classified into three subgroups. These subgroups differed significantly on pain and other symptoms, and functional disability.

CONCLUSION

Both hip and knee patients reported pain and other osteoarthritis symptoms and functional disability and consequently had high expectations in these areas for treatment outcomes. Higher expectations were characterized by more pain, more symptoms and more functional disability. These insights could guide physicians in the discussion of expectations during consultation.

Patient expectation fulfilment following total hip arthroplasty: a 10-year follow-up study

BACKGROUND

The primary aim of this study was to assess how expectation fulfilment changes up to 10 years following total hip arthroplasty (THA).

MATERIALS AND METHODS

Three hundred and forty-six patients completed an expectation questionnaire (encompassing 18 activities), Oxford hip score (OHS) and Short Form (SF)-12 prior to surgery. At 1 year postoperatively, expectation fulfilment was assessed in addition to OHS, SF-12 and patient satisfaction (n = 346). This was repeated in surviving patients with intact THAs at 9.1-9.9 years postoperative (n = 224). Linear regression analysis was used to identify factors independently associated with early (1 year) and late (mean 9.5 years) expectation fulfilment.

RESULTS

Postoperative expectation fulfilment scores declined from 36.5 at 1 year to 33 at late follow-up (95% confidence intervals (CI) 0.0-5.0, p < 0.001). Increased (better) late expectation fulfilment scores were significantly associated with better scores for all PROMs applied at both timepoints. Younger age, greater pre-operative expectation score and greater improvement in OHS (both early and late) were all independent predictors when adjusting for confounding (p < 0.05). At late follow-up 78% (14/18) activities demonstrated high levels of persistent expectation fulfilment. Approximately two out of every five patients who considered themselves unfulfilled at early follow-up went on to experience late fulfilment, but this was dependent upon the specific expectation (mean 40%, range 0-64%).

CONCLUSIONS

Expectation fulfilment following THA changes with time. The majority of patients report high levels of expectation fulfilment following THA at late follow-up. This information can be used to help manage the longer-term expectations of patients undergoing THA.

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Background

There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system.

Objectives

To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement.

Design

(1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness.

Setting

Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England.

Participants

Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement.

Interventions

Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation).

Main outcome measures

Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years.

Results

Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole.

Limitations

Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors.

Conclusion

No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts.

Future work

There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals.

Study registration

This study is registered as PROSPERO CRD42017059473.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

Patient expectations and satisfaction 6 and 12 months following total hip and knee replacement

PURPOSE

To assess (1) patient expectations before total hip (THR) and knee (TKR) replacement; (2) which expectations are met and unmet 6 and 12 months post-surgery; (3) the role of unmet expectations in satisfaction.

METHODS

Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR. Patients listed their own expectations and also completed the Hospital for Special Surgery (HSS) Expectation Survey. We used content analysis to group expectations into themes. At 6 and 12 months post-surgery, patients were given a copy of their own list of individual expectations and reassessed each one as met or unmet. We also assessed fulfilled HSS expectations and satisfaction with surgery.

RESULTS

The sample of 556 patients (49% THR, 57% female) had a mean age of 64 years (SD10). The five most frequent expectation themes were pain relief, mobility, walking, physical activities, and daily activities. Of these, physical activities had the lowest percentage met 12 months post-surgery. 95% (THR) and 87% (TKR) were satisfied/very satisfied with their surgery 12 months post-surgery. Very satisfied patients had a significantly greater percentage of met expectations (96% THR; 92% TKR) than dissatisfied patients (42% THR; 12% TKR). Although most expectations listed by patients were included in the HSS surveys, some were not, particularly for TKR. From 6 to 12 months, there was a significant increase in patient satisfaction for self-care, daily activities, and met expectations for THR and pain relief, self-care, daily activities, and recreational activities for TKR.

CONCLUSIONS

Expectations should be explicitly addressed before surgery, including a discussion of realistic expectations, particularly for physical activities.

Geographical Variation in Outcomes of Primary Hip and Knee Replacement

IMPORTANCE

Little is known about variation in outcomes of surgery or about the factors associated with such variation.

OBJECTIVES

To evaluate variation in patient outcomes and costs for primary hip and knee replacement across health areas in England and to identify whether patient, surgical, or hospital factors are associated with such variation.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the National Joint Registry, linked to English Hospital Episode Statistics and Patient Reported Outcome Measures data sets, for 383 382 adult patients who underwent primary total hip replacement (THR) or primary total and unicompartmental knee replacement (TKR) surgical procedures from January 2014 to December 2016. Geographical Information Systems were used to display maps describing adjusted estimates of variation in outcomes across health areas. Data analysis took place from January 2018 to August 2019.

EXPOSURES

Patient characteristics (eg, age, sex, body mass index [BMI], and socioeconomic deprivation), surgical factors (eg, surgeon volume and grade), and hospital organizational factors (eg, number of operating theaters, number of specialist consultants, and hospital volume).

MAIN OUTCOMES AND MEASURES

Length of stay (LOS), bed-day costs, change in Oxford hip or knee scores 6 months after surgery, and complications 6 months after surgery.

RESULTS

A total of 173 107 patients (mean [SD] age, 69.3 [10.7] years; mean [SD] BMI, 28.9 [5.2]) underwent primary THR and 210 275 patients (mean [SD] age 69.7 [9.4] years; mean [SD] BMI, 31.1 [5.5]) underwent primary TKR, nested in 207 health areas. A number of factors were associated with longer LOS, higher bed-day costs, smaller changes in Oxford hip or knee scores, and a higher percentage of complications, including a workforce with a higher number of less experienced physicians (eg, LOS for less experienced surgeons, THR: regression coefficient, 0.02; 95% CI, 0.01 to 0.03; P < .001; TKR: regression coefficient, 0.01; 95% CI, 0.01 to 0.02; P < .001), public hospitals (eg, bed-day costs for private hospitals, THR: regression coefficient, -0.15; 95% CI, -0.15 to -0.14; P < .001; TKR: regression coefficient, -0.19; 95% CI, -0.19 to -0.19; P < .001), low volume of surgical procedures per surgeon (eg, change in Oxford hip or knee scores for lead surgeon with ≤10 vs >150 surgical procedures per year, THR: regression coefficient, -1.03; 95% CI, -1.47 to -0.58; P < .001; TKR: regression coefficient, -0.54; 95% CI, -1.01 to -0.06), and low volume of surgical procedures per hospital (eg, percentage of complications for hospitals with ≤200 vs ≥500 surgical procedures per year, THR: regression coefficient, 0.12; 95% CI, 0.04 to 0.21; P < .001; TKR: regression coefficient, 0.09; 95% CI, 0.01 to 0.18; P = .03). Although these factors did not attenuate the magnitude of variation across health areas, they had ecological correlations with the observed geographical variations in outcomes of surgery by health area. For example, the percentage of public and private hospitals was ecologically correlated at the health area level with longer and shorter stays, respectively (public hospital, THR: ρ, 0.41; public hospital, TKR: ρ, 0.44; private hospital, THR: ρ, -0.37; private hospital, THR: ρ, -0.38). Across health areas, estimated mean length of stay ranged from 3 to 7 days, and associated bed-day costs ranged from £4727 ($5827) to £8800 ($10 848) for both total hip and knee replacement. The absolute estimated mean change in Oxford hip score varied from 18.7 to 24.6 points and, for Oxford knee score, from 13.1 to 18.8. Estimated 6-month complications ranged from 2.9% to 5.8% for both THR and TKR.

CONCLUSIONS AND RELEVANCE

In this study, models indicated that higher surgical volume by surgeon and by hospital as well as private hospitals were associated with better patient outcomes, which could be explained by the changing case mix of public hospitals treating an increasing number of more complex patients. A higher proportion of less experienced physicians was associated with poorer outcomes. This variation was observed geographically.

Expectations and depression in patients who have undergone total hip arthroplasty in Japan: A prospective cohort study

BACKGROUND

Patients with hip osteoarthritis may be severely depressed preoperatively due to pain and limited daily-living activities. Hence, evaluating their expectations preoperatively might underestimate their true hopes regarding the upcoming total hip arthroplasty (THA).

AIM

We aimed to assess changes in patients' level of depression, understand their expectations and fulfillment, and identify factors affecting fulfillment.

METHOD

We performed a longitudinal study of 366 Japanese patients who had undergone THA during 2005-2006. Those with THA of the contralateral hip were excluded. Patients' expectations, fulfillment, depression, and physical function were assessed perperative and at 6 weeks and one year postoperatively using our own questionnaire, the Arthritis Impact Measurement Scale 2, and by the Oxford Hip Score . Logistic regression analysis was applied to identify independent predictors of expectation fulfillment.

RESULTS

At 6 weeks, 78.1% expressed expectation fulfillment and drastic alleviation of depression. Preoperative depression and fulfillment of patient expectations at 6 weeks were significant predictors of expectation fulfillment at 1 year (95% confidence intervals: 1.01-2.48 and 2.30-9.92, respectively.

CONCLUSIONS

It is worthwhile for health providers to investigate patients' expectations early in the postoperative period by considering their preoperative depression to confirm fulfillment of expectations.

Total hip and knee replacement and return to work: clinicians' perspectives

PURPOSE

An ageing workforce means that our understanding of return to work following total hip and knee replacement is of increasing importance. The purpose of this qualitative study was to explore the views and experiences of clinicians in treating working patients undergoing total hip or knee replacement.

MATERIALS AND METHODS

We conducted semi-structured interviews in primary and secondary National Health Service care using framework methodology. A total of 40 interviews were conducted. Participants included 12 hospital-based Allied Health Professionals and nurses, 12 orthopedic surgeons, and 16 General Practitioners. Data were analyzed thematically.

RESULTS

A key theme concerned participants' perceptions and experiences around the process and practice of listing working patients for total hip or knee replacement. Four sub-themes were identified; the perceived likelihood of listing employed patients for surgery, expectations and outcomes of surgery, the impact of work issues, and referral procedures and waiting lists.

CONCLUSIONS

Decisions around listing working patients for total hip and knee replacement are complex and difficult. Clinicians need to consistently consider patients' work issues, and to be supported in this by appropriate commissioning and service delivery decisions. Further research is indicated to better understand the work-related expectations and anticipated outcomes of both patients and clinicians, and the optimum timing of surgery to maintain and improve patients' work performance.Implications for rehabilitationClinicians need to consistently consider patients' work issues, and current evidence, in their consultations and decisions regarding total hip and knee replacement.Clinical practice should reflect the growing proportion of working patients undergoing total hip and knee replacement, and routinely measure work outcomes.Changes are required at commissioning and service levels to support clinicians in changing their practice with this patient population.

Preoperative Radiographic Osteoarthritis Severity Modifies the Effect of Preoperative Pain on Pain/Function After Total Knee Arthroplasty: Results at 1 and 2 Years Postoperatively

BACKGROUND

Osteoarthritis (OA) severity as demonstrated by preoperative radiographs and preoperative pain play an important role in the indication for total knee arthroplasty (TKA). We investigated whether preoperative radiographic evidence of OA severity modified the effect of preoperative self-reported pain on postoperative pain and function 1 and 2 years after TKA for OA.

METHODS

Data from the Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study (LOAS), a multicenter cohort study on outcomes after TKA, were used. OA severity was assessed radiographically with the Kellgren and Lawrence (KL) score (range, 0 to 4). Pain and function were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS). After adjustment for body mass index (BMI), age, sex, and the Mental Component Summary scores from the Short Form-12, multivariate linear regression analyses with an interaction term between the preoperative KL score and preoperative pain were performed.

RESULTS

The study included 559 patients. The preoperative KL score was independently associated with 1-year postoperative pain and function (β = 5.4, 95% confidence interval [CI] = 1.4 to 9.4, and β = 7.7, 95% CI = 3.2 to 12.2), while preoperative pain was associated only with postoperative pain (β = 0.3, 95% CI = 0.1 to 0.6) and not with postoperative function (β = 0.2, 95% CI = -0.2 to 0.5). Comparable associations were found between 2-year postoperative pain and KL score (β = 8.0, 95% CI = 3.2 to 12.7) and preoperative pain (β = 0.5, 95% CI = 0.1 to 0.8) and between 2-year postoperative function and KL score (β = 7.7, 95% CI = 3.2 to 12.2). The study showed a trend toward the KL score modifying the effect of preoperative pain on 1-year postoperative pain (β = -0.1, 95% CI = -0.1 to 0.0) and 2-year postoperative pain (β = -0.1, 95% CI = -0.2 to 0.0) and on 1 and 2-year function (β = -0.1, 95% CI = -0.2 to 0.0 for both), with the effect of preoperative pain on postoperative pain and function seeming to become less important when there was radiographic evidence of greater preoperative OA severity.

CONCLUSIONS

Patients with less pain and higher KL grades preoperatively had better function and pain outcomes 1 and 2 years after TKA. However, the effect of preoperative pain on the postoperative outcomes seems to become less important when the patient has radiographic evidence of more severe OA. We believe that analysis of the severity of preoperative pain is an important proxy for optimal postoperative patient outcome.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Predicting Outcome after Total Hip Arthroplasty: The Role of Preoperative Patient-Reported Measures

Choosing the appropriate patient for surgery is crucial for good outcome in total hip arthroplasty (THA). Therefore, parameters predicting outcome preoperatively are of major interest. In the current study, we compared the predictive power of different presurgical measures in minimally invasive THA. In the course of a prospective clinical trial preoperative HOOS, EQ-5D and SF-36 were obtained in 140 patients undergoing THA. Responder rate was defined by the modified OMERACT-OARSI criteria at six-month-, one-year, two-year, and three-year follow-up. Logistic regression was performed to compare the different questionnaires regarding their power of predicting positive responders. ROC-curve analysis was used to define benchmarks in preoperative measures associated with good outcome. Preoperative HOOS (p<0.001), EQ-5D (p=0.007), and PCS of SF-36 (p<0.001) were higher in responders than in nonresponders whereas no differences between responders and nonresponders were found for preoperative MCS (p=0.96) of SF-36. However, preoperative HOOS revealed best predictive power (OR=0.84 95%CI=0.78-0.90, p<0.001, Pseudo R-Squared according to Nagelkerke=0.48, effect size according to Cohen=0.96) compared to all other preoperative measures. Multivariable analysis confirmed preoperative HOOS as an independent parameter correlating with postoperative responder status (OR=0.76, 95% CI=0.66–0.88, p<0.001). In ROC-curve analysis nonresponders were identified with a sensitivity of 91.7% and specificity of 68.9% using a cutoff in preoperative HOOS of 40.3. Presurgical HOOS can predict outcome in THA better than other preoperative outcome measures. Patients with a preoperative HOOS value less than 40.3 have the highest probability of a positive response in terms of pain and function after THA.

Patient expectations and satisfaction in orthopaedic surgery: A review of the literature

Patient expectations have been shown to be an independent predictor of outcomes in clinical medicine. In the orthopaedic literature, the majority of studies have focused on the relationship between pre-operative expectations and post-operative outcomes in patients undergoing total hip arthroplasty, total knee arthroplasty, shoulder surgery, and spine surgery. Various methodologies have been used to assess patient expectations in orthopaedic surgery, including direct questioning, short questionnaires, and validated surveys. Multiple patient factors have been associated with greater expectations prior to elective orthopaedic surgery, and greater pre-operative expectations have been shown to be associated with better subjective and objective outcomes after total hip and knee arthroplasty, shoulder surgery, and spine surgery. While there are very few validated measures of patient satisfaction after orthopaedic surgery, increased post-operative patient satisfaction is consistently associated with meeting pre-operative patient expectations. Given the relationship between pre-operative patient expectations and post-operative outcomes and patient satisfaction, understanding and defining expectations prior to elective orthopaedic surgery may optimize outcomes. In this review, we aim to summarize the current literature on patient expectations in orthopaedic surgery.

Early recovery trajectories after fast-track primary total hip arthroplasty: the role of patient characteristics

Background and purpose - Little is known about heterogeneity in early recovery after primary total hip arthroplasty (THA). Therefore, we characterized subgroups of patients according to their hip function trajectory during the first 6 weeks after THA in a fast-track setting. Patients and methods - 94 patients (median age 65 years [41-82], 56 women) from a single hospital participated in a diary study. Patients recorded their severity of hip problems (Oxford Hip Score, OHS) weekly for 6 weeks after THA. Latent class growth modelling (LCGM) was used to identify patients with the same hip function trajectory and to compare these subgroups on patient characteristics. Results - LCGM revealed a fast (n = 17), an average (n = 53), and a slow (n = 24) recovery subgroup. Subgroups differed on the estimated weekly growth rate during the first 2 weeks (fast: 9.5; average: 5.3; slow: 2.7), with fewer differences between groups in the last 4 weeks (fast: 0.90; average: 2.0; slow: 1.7). Patients in the slow recovery group could be characterized as women of older age (mean age =69) who rated their health as lower preoperatively, needed more assistance during recovery, and were less satisfied with the outcomes of the surgery. Interpretation - We identified distinct recovery trajectories in the first 6 weeks after fast-track primary THA which were associated with patient characteristics.

Effect of preoperative patient expectations on outcomes after reverse total shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the effect of preoperative expectations on outcomes after reverse shoulder arthroplasty (RSA). We hypothesized that patients with greater expectations would have better outcomes.

METHODS

Patients undergoing primary RSA completed the Hospital for Special Surgery's Shoulder Expectations Survey preoperatively. Preoperative and 2-year postoperative clinical outcomes were measured with the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Shoulder Activity Scale (SAS), 36-Item Short Form Health Survey (SF-36), and visual analog scales (VASs). Pearson correlations were used to assess the relationship between the number of expectations and outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation question were assessed by independent samples t test. Multivariable linear regression analysis was used to control for potential confounding factors.

RESULTS

We evaluated 135 patients at 2 years postoperatively. Patients had higher expectations for relieving pain, improving self-care, improving ability to perform daily activities, and improving ability to drive or put on a seatbelt. Patients with a greater number of high expectations preoperatively did not have better ASES, SAS, or VAS pain scores postoperatively. However, higher expectations for relieving nighttime pain was associated with ASES (β = 7.0, P = .048) and VAS pain scores (β = -5.9, P = .047) as well as 2-year improvement of VAS pain (β = -6.1, P = .039). Higher expectations for improving the ability to participate in nonoverhead sports was associated with improvements in SAS (β = 2.8, P = .020).

CONCLUSION

A higher level of expectations for relief of nighttime pain and improving ability to participate in nonoverhead sports is associated with improved outcomes after RSA.

Is gain in health-related quality of life after a total hip arthroplasty depended on the comorbidity burden?

Background and purpose - Using patient-reported health-related quality of life (HRQoL), approximately 10% of patients report some degree of dissatisfaction after a total hip arthroplasty (THA). The preoperative comorbidity burden may play a role in predicting which patients may have limited benefit from a THA. Therefore, we examined whether gain in HRQoL measured with the EuroQol-5D (EQ-5D) at 3 and 12 months of follow-up depended on the comorbidity burden in THA patients Patients and methods - 1,582 THA patients treated at the Regional Hospital West Jutland from 2008 to 2013 were included. The comorbidity burden was collected from an administrative database and assessed with the Charlson Comorbidity Index (CCI). The CCI was divided into 3 levels: no comorbidity burden, low, and high comorbidity burden. HRQoL was measured using the EQ-5D preoperatively and at 3 and 12 months' follow-up. Association between low and high comorbidity burden compared with no comorbidity burden and gain in HRQoL was analyzed with multiple linear regression. Results - All patients, regardless of comorbidity burden, gained significantly in HRQoL. A positive association between comorbidity burden and gain in HRQoL was found at 3-month follow-up for THA patients with a high comorbidity burden (coeff: 0.09 (95% CI 0.02 - 0.16)) compared with patients with no comorbidity burden. Interpretation - A comorbidity burden prior to THA does not preclude a gain in HRQoL up to 1 year after THA.

The influence of preoperative determinants on quality of life, functioning and pain after total knee and hip replacement: a pooled analysis of Dutch cohorts

Background

Previous research has identified preoperative determinants that predict health related quality of life (HRQoL), functioning and pain after total knee or hip arthroplasty (TKA/THA), but these differed between studies and had opposite directions. This may be due to lack of power and not adjusting for confounders. The present study aims to identify the preoperative determinants that influence health related quality of life (HRQoL), functioning and pain after total knee or hip arthroplasty (TKA/THA).

Methods

We pooled individual patient from 20 cohorts with OA patients data (n = 1783 TKA and n = 2400 THA) in the Netherlands. We examined the influence of age, gender, BMI and preoperative values of HRQoL, functioning and pain on postoperative status and total improvement. Linear mixed models were used to estimate the effect of each preoperative variable on a particular outcome for each cohort separately. These effects were pooled across cohorts using a random effects model.

Results

For each increase in preoperative point in HRQoL, the postoperative HRQoL increased by 0.51 points in TKA and 0.37 points in THA (SF-36 scale). Similarly, each point increase in preoperative functioning, resulted in a higher postoperative functioning of 0.31 (TKA) and 0.21 (THA) points (KOOS/HOOS-ADL scale). For pain this was 0.18 (TKA) and 0.15 (THA) points higher (KOOS/HOOS-pain scale) (higher means less pain). Even though patients with better preoperative values achieved better postoperative outcomes, their improvement was smaller. Women and patients with a higher BMI had more pain after a TKA and THA. Higher age and higher BMI was associated with lower postoperative HRQoL and functioning and more pain after a THA.

Conclusions

Patients with a better preoperative health status have better outcomes, but less improvement. Even though the independent effects may seem small, combined results of preoperative variables may result in larger effects on postoperative outcomes.

Development and validation of a shared decision-making instrument for health-related quality of life one year after total hip replacement based on quality registries data

RATIONALE, AIMS AND OBJECTIVES

Clinicians considering improvements in health-related quality of life (HRQoL) after total hip replacement (THR) must account for multiple pieces of information. Evidence-based decisions are important to best assess the effect of THR on HRQoL. This work aims at constructing a shared decision-making tool that helps clinicians assessing the future benefits of THR by offering predictions of 1-year postoperative HRQoL of THR patients.

METHODS

We used data from the Swedish Hip Arthroplasty Register. Data from 2008 were used as training set and data from 2009 to 2012 as validation set. We adopted two approaches. First, we assumed a continuous distribution for the EQ-5D index and modelled the postoperative EQ-5D index with regression models. Second, we modelled the five dimensions of the EQ-5D and weighted together the predictions using the UK Time Trade-Off value set. As predictors, we used preoperative EQ-5D dimensions and the EQ-5D index, EQ visual analogue scale, visual analogue scale pain, Charnley classification, age, gender, body mass index, American Society of Anesthesiologists, surgical approach and prosthesis type. Additionally, the tested algorithms were combined in a single predictive tool by stacking.

RESULTS

Best predictive power was obtained by the multivariate adaptive regression splines (R²  = 0.158). However, this was not significantly better than the predictive power of linear regressions (R²  = 0.157). The stacked model had a predictive power of 17%.

CONCLUSIONS

Successful implementation of a shared decision-making tool that can aid clinicians and patients in understanding expected improvement in HRQoL following THR would require higher predictive power than we achieved. For a shared decision-making tool to succeed, further variables, such as socioeconomics, need to be considered.

Expectations and experiences of patients with osteoarthritis undergoing total joint arthroplasty: An integrative review

BACKGROUND

The effectiveness of educational interventions for osteoarthritic patients undergoing total joint arthroplasty remains inconclusive. It is essential to understand the educational needs of these patients from their perspectives.

AIM

The aim of this study was to systematically summarize and synthesize osteoarthritic patients' expectations and experiences in undergoing total joint arthroplasty to identify their educational needs.

DESIGN

An integrative review was conducted.

METHODS

Twenty studies (13 qualitative and 7 quantitative), published between 2006 and 2016, were independently appraised by 2 reviewers using the Critical Appraisal Skills Programme checklist for qualitative studies and the Joanna Briggs Institute Critical Appraisal Tools for quantitative studies. Data were analysed using thematic analysis, and the findings were synthesized in a narrative summary.

RESULTS

Six themes describing patients' preoperative and post-operative educational needs were identified: (1) preoperative anxiety, (2) unrealistic expectations of recovery, (3) post-operative pain, (4) regaining functional abilities, (5) physical and psychological sense of loss, and (6) lack of continuity of care.

CONCLUSION

This review is the first to capture the osteoarthritic patients' educational needs from their perspectives. The biopsychosocial model can address the multidimensionality (biological, psychological, and social) of patients' educational needs. A robust infrastructure supporting interprofessional collaborative practice and continuity of care should be adopted to enhance current educational efforts.

Do Patient Expectations Influence Patient-Reported Outcomes and Satisfaction in Total Hip Arthroplasty? A Prospective, Multicenter Study

BACKGROUND

The relationship between patient expectations and patient-reported outcomes (PROs) in total hip arthroplasty (THA) patients is controversial. The purpose of this study was to examine the impact of preoperative patient expectations on postoperative PROs and patient satisfaction.

METHODS

This was a prospective multicenter observational cohort study of primary THA patients. Preoperatively, patients completed Hospital for Special Surgery (HSS) Hip Replacement Expectations Survey (expectations), 12 item Short Form Survey (SF-12), University of California, Los Angeles (UCLA) activity score, and Hip Disability and Osteoarthritis Score (HOOS). Postoperatively at 6 months and 1 year, patients completed the Hospital for Special Surgery Hip Replacement Fulfillment of Expectations Survey (fulfillment of expectations), a satisfaction survey, and the same PROs as preoperatively. Stepwise multivariate regression models were created.

RESULTS

A total of 207 patients were enrolled. Follow-up rate was 91% at 6 months and 92% at 1 year. Being employed and lower baseline HOOS predicted higher expectations (employment status: B = -7.5, P = .002; HOOS: B = -0.27, P = .002). Higher preoperative expectations predicted greater improvements in UCLA activity, SF-12 physical component score, and HOOS at 6 months (UCLA activity: B = 0.03, P = .001; SF-12 physical component score: B = 0.15, P = .001; HOOS: B = 0.20; P = .008) and UCLA activity at 1 year (B = 0.02, P = .004). Furthermore, higher expectations predicted higher postoperative satisfaction and fulfillment of expectations at 6 months (satisfaction: B = 0.21, P < .001; fulfillment of expectations: B = 0.30, P < .001) and higher fulfillment of expectations at 1 year (B = 0.17, P = .006).

CONCLUSION

In patients undergoing THA, being employed and worse preoperative hip function predict of higher preoperative expectations of surgery. Higher expectations predict greater improvement in PROs, greater patient satisfaction, and the fulfillment of expectations. These findings can be used to guide patient counseling and shared decision making preoperatively.

Preoperative psychosocial factors predicting patient's functional recovery after total knee or total hip arthroplasty: a systematic review

OBJECTIVE

To evaluate the predictive value of preoperative psychosocial factors on the perceived and observed postoperative patient's functional recovery during the post-hospital phase and up to 12 months after hospital discharge of patients who underwent total knee or total hip arthroplasty.

METHODS

A systematic review was performed. MEDLINE, CINAHL, EMBASE and PsychINFO were systematically screened in order to find prospective longitudinal studies. Risk of bias was assessed using a modified version of a 27-item checklist for prognostic studies, as previously used by Veerbeek. A qualitative analysis was performed using the method of Zwikker.

RESULTS

A total of 26 studies, with a total of 11,020 patients, were included. In total, 22 studies were judged as having a high risk of bias. Overall, no longitudinal association with perceived or observed functional recovery was found in all of the seven preoperative psychosocial categories: A: mental well-being, B: cognitions, C: beliefs, D: expectations, E: coping, F: social support or G: personality traits in total joint arthroplasty. Mental well-being seems to be the exception in one time period (>6 weeks through ≤3 months) and change score in observed functional recovery, but only in patients awaiting total knee arthroplasty (100% and 75% of the variables were significantly and consistently associated, respectively).

CONCLUSION

Overall, the results of this systematic review suggest that there is no longitudinal association between preoperative psychosocial factors and perceived or observed patient's postoperative functional recovery after total joint arthroplasty. The psychological category mental well-being is related to observed postoperative recovery >6 weeks through ≤3 months and to change score after total knee arthroplasty.

Effect of pre-operative expectations on the outcomes following total shoulder arthroplasty

Aims

Few studies have evaluated the relationship between patients’ pre-operative expectations and the outcome of orthopaedic procedures. Our aim was to determine the effect of expectations on the outcome after primary anatomical total shoulder arthroplasty (TSA). We hypothesised that patients with greater expectations would have better outcomes.

Patients and Methods

Patients undergoing primary anatomical TSA completed the Hospital for Special Surgery’s Shoulder Expectations Survey pre-operatively. The American Shoulder and Elbow Surgeons (ASES), Shoulder Activity Scale (SAS), Short-Form-36 (SF-36), and visual analogue scale (VAS) for pain, fatigue, and general health scores were also collected pre-operatively and two years post-operatively. Pearson correlations were used to assess the relationship between the number of expectations and the outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation were assessed by independent samples t-test. Multivariable linear regression analysis was used to control for potential confounding factors.

Results

A total of 67 patients were evaluated two years post-operatively. Most parameters of outcome improved significantly from baseline and most patients were satisfied. A greater number of expectations was associated with a significantly greater improvement in the ASES score (p = 0.02). In the multivariable analysis, a greater number of expectations was an independent predictor of better ASES, VAS and SF-36 scores, as well as improvements in ASES and VAS pain scores (p < 0.05). Greater expectations for many specific expectation questions were significantly associated with better outcomes (p < 0.05).

Conclusion

TSA is a successful procedure with significant improvements in outcome, and greater pre-operative expectations are associated with better outcomes. Cite this article: Bone Joint J 2017;99-B:1190–6.

A prospective cohort study examining medical and social factors associated with engagement in life activities following total hip replacement

OBJECTIVES

Studies show limited improvement in the frequency of engaging in life activities after joint replacement. However, there is a paucity of research that has examined factors, including other life events, which influence engagement following total hip replacement (THR). This research sought to identify factors associated with engaging in life activities following THR.

METHODS

A prospective cohort study was conducted with 376 people who had a THR for osteoarthritis (OA). Data were collected pre-surgery and 1 year post-surgery. The primary outcome was change in frequency in engagement in life activities (Late Life Disability Index (LLDI): higher scores indicate higher frequency of engagement (range 0-80)). Analyses included multivariable regression. Factors considered included: positive/negative life events, a new comorbidity, another joint replacement and complications post-surgery.

RESULTS

Participants' mean age was 64 years; 46% were male. 68% of participants had at least one comorbidity pre-surgery; 36% reported at least one new comorbidity after surgery. The mean change in LLDI frequency was an increase of 6.29 (±8.10). 36% reported one or more positive impact life events in the year following surgery; 63% reported one or more negative life events. The number of positive life events (beta = 1.24; 95% CI: 0.49, 1.99) was significantly associated with change in LLDI frequency after adjusting for age, sex, education, body mass index (BMI), comorbidities pre-surgery, number of symptomatic joints and pre-surgery pain and function, LLDI limitations and depression.

CONCLUSIONS

These findings highlight the significant influence of social factors and life circumstances on engagement in life activities following THR.

Negative expectations interfere with the analgesic effect of safety cues on pain perception by priming the cortical representation of pain in the midcingulate cortex

It is well known that the efficacy of treatment effects, including those of placebos, is heavily dependent on positive expectations regarding treatment outcomes. For example, positive expectations about pain treatments are essential for pain reduction. Such positive expectations not only depend on the properties of the treatment itself, but also on the context in which the treatment is presented. However, it is not clear how the preceding threat of pain will bias positive expectancy effects. One hypothesis is that threatening contexts trigger fearful and catastrophic thinking, reducing the pain-relieving effects of positive expectancy. In this study, we investigated the disruptive influence of threatening contexts on positive expectancy effects while 41 healthy volunteers experienced laser-induced heat pain. A threatening context was induced using pain-threatening cues that preceded the induction of positive expectancies via subsequent pain-safety cues. We also utilised electroencephalography (EEG) to investigate potential neural mechanisms underlying these effects. Lastly, we used the Fear of Pain Questionnaire to address whether the disruptive effect of negative contexts on cued pain relief was related to the degree of fear of pain. As predicted, participants responded less to pain-safety cues (i.e., experienced more pain) when these were preceded by pain-threatening cues. In this threatening context, an enhancement of the N2 component of the laser-evoked potential was detected, which was more pronounced in fearful individuals. This effect was localised to the midcingulate cortex, an area thought to integrate negative affect with pain experience to enable adaptive behaviour in aversive situations. These results suggest that threatening contexts disrupt the effect of pain relief cues via an aversive priming mechanism that enhances neural responses in the early stages of sensory processing.

Lower limb arthroplasty: can we produce a tool to predict outcome and failure, and is it cost-effective? An epidemiological study

Background

Although hip and knee arthroplasties are considered to be common elective cost-effective operations, up to one-quarter of patients are not satisfied with the operation. A number of risk factors for implant failure are known, but little is known about the predictors of patient-reported outcomes.

Objectives

(1) Describe current and future needs for lower limb arthroplasties in the UK; (2) describe important risk factors for poor surgery outcomes and combine them to produce predictive tools (for hip and knee separately) for poor outcomes; (3) produce a Markov model to enable a detailed health economic analysis of hip/knee arthroplasty, and for implementing the predictive tool; and (4) test the practicality of the prediction tools in a pragmatic prospective cohort of lower limb arthroplasty.

Design

The programme was arranged into four work packages. The first three work packages used the data from large existing data sets such as Clinical Practice Research Datalink, Hospital Episode Statistics and the National Joint Registry. Work package 4 established a pragmatic cohort of lower limb arthroplasty to test the practicality of the predictive tools developed within the programme.

Results

The estimated number of total knee replacements (TKRs) and total hip replacements (THRs) performed in the UK in 2015 was 85,019 and 72,418, respectively. Between 1991 and 2006, the estimated age-standardised rates (per 100,000 person-years) for a THR increased from 60.3 to 144.6 for women and from 35.8 to 88.6 for men. The rates for TKR increased from 42.5 to 138.7 for women and from 28.7 to 99.4 for men. The strongest predictors for poor outcomes were preoperative pain/function scores, deprivation, age, mental health score and radiographic variable pattern of joint space narrowing. We found a weak association between body mass index (BMI) and outcomes; however, increased BMI did increase the risk of revision surgery (a 5-kg/m2rise in BMI increased THR revision risk by 10.4% and TKR revision risk by 7.7%). We also confirmed that osteoarthritis (OA) severity and migration pattern of the hip predicted patient-reported outcome measures. The hip predictive tool that we developed performed well, with a correctedR2of 23.1% and had good calibration, with only slight overestimation of Oxford Hip Score in the lowest decile of outcome. The knee tool developed performed less well, with a correctedR2of 20.2%; however, it had good calibration. The analysis was restricted by the relatively limited number of variables available in the extant data sets, something that could be addressed in future studies. We found that the use of bisphosphonates reduced the risk of revision knee and hip surgery by 46%. Hormone replacement therapy reduced the risk by 38%, if used for at least 6 months postoperatively. We found that an increased risk of postoperative fracture was prevented by bisphosphonate use. This result, being observational in nature, will require confirmation in a randomised controlled trial. The Markov model distinguished between outcome categories following primary and revision procedures. The resulting outcome prediction tool for THR and TKR reduced the number and proportion of unsatisfactory outcomes after the operation, saving NHS resources in the process. The highest savings per quality-adjusted life-year (QALY) forgone were reported from the oldest patient subgroups (men and women aged ≥ 80 years), with a reported incremental cost-effectiveness ratio of around £1200 saved per QALY forgone for THRs. In the prospective cohort of arthroplasty, the performance of the knee model was modest (R2 = 0.14) and that of the hip model poor (R2 = 0.04). However, the addition of the radiographic OA variable improved the performance of the hip model (R2 = 0.125 vs. 0.110) and high-sensitivity C-reactive protein improved the performance of the knee model (R2 = 0.230 vs. 0.216). These data will ideally need replication in an external cohort of a similar design. The data are not necessarily applicable to other health systems or countries.

Conclusion

The number of total hip and knee replacements will increase in the next decade. High BMI, although clinically insignificant, is associated with an increased risk of revision surgery and postoperative complications. Preoperative pain/function, the pattern of joint space narrowing, deprivation index and level of education were found to be the strongest predictors for THR. Bisphosphonates and hormone therapy proved to be beneficial for patients undergoing lower limb replacement. The addition of new predictors collected from the prospective cohort of arthroplasty slightly improved the performance of the predictive tools, suggesting that the potential improvements in both tools can be achieved using the plethora of extra variables from the validation cohort. Although currently it would not be cost-effective to implement the predictive tools in a health-care setting, we feel that the addition of extensive risk factors will improve the performances of the predictive tools as well as the Markov model, and will prove to be beneficial in terms of cost-effectiveness. Future analyses are under way and awaiting more promising provisional results.

Future work

Further research should focus on defining and predicting the most important outcome to the patient.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Nonspecific Feelings Expected and Experienced during or Immediately after Electroacupuncture: A Pilot Study in a Teaching Situation

BACKGROUND

Some feelings elicited by acupuncture-type interventions are "nonspecific", interpretable as resulting from the placebo effect, our own self-healing capacities-or, indeed, the flow of qi. Expectation is thought to contribute to these nonspecific effects. Here we describe the use of two innovative 20-item questionnaires (EXPre₂₀ and EXPost₂₀) in a teaching situation.

METHODS

Respondents were acupuncture students or practitioners on electroacupuncture (EA) training courses (N = 68). EXPre₂₀ and EXPost₂₀ questionnaires were completed before and after receiving individualised treatment administered by colleagues. Respondents were also asked about their prior experience of EA or transcutaneous electroacupuncture stimulation (TEAS).

RESULTS

Respondents expected significantly more items to change than not to change, but significantly fewer were experienced as changing. Increases in given questionnaire items were both expected and experienced significantly more often than decreases. "Tingling", "Relaxation", and "Relief" or "Warmth" were most often expected to increase or were experienced as such, and "Pain" and "Tension" to decrease or experienced as decreasing. Expectations of change or no change were confirmed more often than not, particularly for "Tingling" and "Tension". This was not the result of the personal respondent style. Cluster analysis suggested the existence of two primary feeling clusters, "Relaxation" and "Alertness".

CONCLUSIONS

Feelings experienced during or immediately after acupuncture-type interventions may depend both on prior experience and expectation.